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To print this form, you may select the text (beginning at Pet's Name and continuing to the end of the printed owner's name line). Once text is selected, go to File (top left of your browser screen) and select print. When the print box is open, click the option that says Print Selection. From my computer and using Microsoft's Internet Explorer, this prints as a two-page form. I strongly reccommend you print TWO of these forms. One for me to retain in your file AND one you can leave with your vet in your pets file.
Coddled Critters In Home Pet Services
281-728-9001 * firstname.lastname@example.org
BONDED AND INSURED
Member PSI, HAPPSA & NAPPS
Veterinary Treatment Authorization & Consent Form
Primary Veterinary Clinic: _____________________________________________________
City: ________________________________________ Zip Code: ______________________
To whom it may concern: During my absence a representative of Coddled Critters will be caring for my pet(s). I give Coddled Critters my permission to transport my pets to you, my veterinarian (or to an emergency clinic). In the event I cannot be reached, I authorize Coddled Critters to act as an agent on my behalf regarding my pets’ medical care. I authorize veterinary treatment and accept full responsibility for charges incurred in the treatment of my pet(s), not to exceed the following amounts for each pet:
Pet Name & Description .....................Maximum Amount if any or N/A
_____ check here if additional pets are listed on the reverse side
If above named veterinarian is not available, another vet in his/her veterinary group is / is not acceptable. ( _____ initial)
I understand that Coddled Critters assumes no responsibility for the loss of any pet and is released from all liability related to transportation, treatment and expense. ( _____ initial)
I do / do not agree to authorize said veterinarian to euthanize my pet in extreme circumstances under his/her advisement after all reasonable attempts have been made to reach me. ( _____ initial)
This consent for treatment has no expiration date unless otherwise noted. A photocopy/facsimile of the signed consent shall have the same force and effect as the Client/Pet Owner’s original signature. ( _____ initial)
After hours and weekends: Animal Emergency Clinic
9920 Hwy 90-A Dairy Ashford
Sugarland, TX 77478
If the veterinary office named above is unavailable, I authorize Coddled Critters to take my pet to the veterinarian office or clinic of their choice for treatment. ( _____ initial)
I have made advance arrangements with your office to pay all charges and fees that are incurred on my behalf, immediately upon my return.
OR PLEASE charge all expenses incurred for veterinary services to this card:
M/C Visa Other ____________ CC# and exp. Date: ______________________________
Name on card:_____________________________________________________________
Signature if different than Pet Owner:__________________________________________
PET OWNER Name: ________________________________________________________
City: __________________________________________________ ZIP: ________________
Home phone: _________________________ Work phone: __________________________
Cell/Pager: ___________________________ Other: _______________________________
This form will be retained on file and will be used to authorize veterinary treatment in the event that your pet(s) require treatment during your absence, while in our care, and we are unable to contact you at the time. Should you change veterinarians please notify Coddled Critters before service dates. A copy will be sent to the primary veterinarian listed above to be retained in the pets’ medical file.
* This form MUST be signed to authorize treatment.
Client Printed Name .....................................................................Signature/ Date
Coddled Critters Sitter Printed Name ..........................................Signature/ Date